Transcript scarica gli atti

La sinfisiodesi pubica
giovanile: opinioni a
confronto
Angela Palumbo Piccionello
[email protected]
Che cos’è
E’ una tecnica recente, che, attraverso
una cauterizzazione della sinfisi pubica,
inibisce la crescita dei rami del pube ma
non quella dell’ileo e della porzione
dorsale degli acetaboli. In questo modo
determina una rotazione ventro-laterale
degli acetaboli, favorendo una migliore
copertura acetabolare e quindi
congruenza articolare.
8 Greyhound femmine
di 4 mesi di età
Risultati
Significativa diminuzione della crescita del
pube
Significativo aumento dell’Angolo di
Norberg
Siignificativa diminuzione dell’Indice di
Distrazione
Significativo aumento dell’Angolo di
Ventroversione dell’Acetabolo
7 Chesapeake Bay Retrievers e 2
beagle
CR1: operato a 12 sett.
CR2: operato a 16 sett.
CR3: operato a 20 sett.
CR7: operato a 22 sett
CR4: operato a 24 sett.
CR5 e CR6: controllo
DI: Gruppo operato: a 44 sett 0,38, a 137sett 0,28
Gruppo non operato: a 44 sett 0,78, a 137
sett 0,66
ID diminuito significativamente negli
operati rispetto ai non operati.
!
DJD: Gruppo operato: a 137 sett 1+ di artrosi ad
eccezione di CR4 che presentava 2+
Gruppo non operato: 2+ di artrosi.
!
AA:
Fig 1 a12 sett (prima dell’intervento)
Fig.2 a 137 settimane di età.
ANGOLO ACETABOLARE:
Gruppo operato: Preop 56°, 44 sett 78, 137 sett 81°
Gruppo non operato: 16 sett 57,4°, 44 sett 60°, 137 sett 58°
Clinical Communication
© 2008
267
Schattauer GmbH
Comparison of conservative management
and juvenile pubic symphysiodesis in the early
treatment of canine hip dysplasia
A. Vezzoni1, G. Dravelli1, L. Vezzoni1, M. De Lorenzi1, A. Corbari1, A. Cirla1, C. Nassuato2,
V. Tranquillo2
1
Clinica Veterinaria Vezzoni, Cremona, Italy
2
Osservatorio Epidemiologico Veterinario della Regione Lombardia, I.Z.S.L.E.R. 'B. Ubertini' Brescia,
Italy
Summary
Objectives: To evaluate the efficacy of juvenile pubic
symphysiodesis (JPS) in a clinical setting for the early
treatment of canine hip dysplasia (CHD), and to identify its indications and contraindications. Methods: The
final degree of CHD using the FCI (Fédération Cynologique Internationale) CHD classification in 5 Grades (A,
B, C, D, E) was assessed at skeletal maturity in two
homogeneous groups of dogs assessed at the age of 14
to 22 weeks and selected according to their susceptibility to CHD; one group was treated with JPS and one
group was conservatively managed. Two hundred
seventeen puppies completed the study; 81 were
treated with JPS (group 1) and 76 were conservatively
managed (group 2). A third group of 60 puppies with
normal hips was followed as a negative control group.
Results: In group 1, 43.2% of the puppies had regression or a lack of progression of the disease in the final
evaluation (Grade A & B), 25.9% had mild CHD (Grade
C) and 30.9% had moderate and severe CHD (Grade D
& E). In group 2, 23.6% of the puppies did not show
any development of the disease (Grade A & B), 21.1%
had mild CHD (Grade C) and 55.3% developed moderate to severe CHD (Grade D & E). Further investigation
was done by comparing the severity of early signs of
susceptibility to CHD with the final FCI Grades at adulthood in both groups. Clinical significance: The JPS
procedure increased the odds of arresting or limiting
the progression of CHD in mild to moderate grades of
CHD, while it was less effective or ineffective in more
severe forms.
Introduction
Canine hip dysplasia (CHD) is the most frequent non-traumatic orthopaedic pathology
found in growing dogs. It is characterised by
a lack of congruity between the articular
surfaces of the femoral head and the acetabular cavity, which inevitably leads to osteoarthritis (OA) (1–4). With early accurate
diagnosis in the growing puppy (4–11), it is
possible to intervene in dysplastic evolution
with prophylactic type surgical procedures,
such as juvenile pubic symphysiodesis
(JPS) (12–16) and triple pelvic osteotomy
(TPO) (17–20). The aim of these surgical
treatments, which are carried out during the
phase of skeletal development of animals
showing signs of susceptibility to CHD, is to
arrest the progression of the disease by reversing the tendency to subluxation, and
avoiding or limiting the development of secondary OA (11–16, 18–20). The fundamental principle on which the JPS and TPO procedures are based is the neutralisation of
forces that tend to make the hip subluxate by
modification of the dorsal acetabular rim
angle (DARA) (19, 20). It is well known that
an increase in the DARA brings about progressive coxofemoral subluxation with ero-
prevent secondary OA (12–16, 18). However, in the most advanced forms of CHD in
young puppies, JPS has proven to be ineffective in the prevention of coxofemoral
subluxation during weight bearing and the
resulting dysplastic joint degeneration (16).
The JPS technique consists of electrocauterization of physeal cartilage of the pubic
symphysis, inducing thermal necrosis of the
germinal chondrocytes and arrest of endochondral bone growth. Premature closure of
the pubic symphysis during the puppy’s
growth causes medial – lateral shortening of
the cranial ramus pubicus, resulting in limitation of the circumferential growth of the
ventral part of the pelvic girdle. This arrest
of ventral growth of the pelvis, associated
with free growth of the dorsal component,
leads to ventral traction on the acetabulum
and outward rotation of the acetabular rim.
The acetabular ventroflexion obtained with
JPS leads to diminution of the DARA and
improvement of joint congruity and therefore greater acetabular coverage of the femoral heads (Fig. 1) (12–16). Encouraged
by these studies carried out by other authors,
we wanted to carry out a prospective clinical
study in order to evaluate the efficacy of JPS
in field conditions and with a large cohort of
dogs with early signs of susceptibility to
217 cani, valutati a 14/22
settimane di vita, divisi in tre
gruppi omogenei (JPS,
Conservativi, sani), poi
rivalutati con la lettura
ufficiale a sviluppo ultimato
La sinfisiodesi pubica aumenta
la probabilità di arrestare o
limitare la progressione della
Displasia dell’Anca, nei pazienti
con patologia di lieve o media
entità, mentre è poco efficace
nelle forme gravi
Quindi…Che cos’è?
E’ una tecnica recente, che nei tempi e
nelle indicazioni adatte è in grado di
migliorare la congruenza articolare
attraverso una ventroversione degli
acetaboli, determinando quindi una
maggiore copertura acetabularie delle
teste femorali e una migliore
congruenza articolare.
Tempi e
indicazioni adatte
SCELTA DEL PAZIENTE
Paziente giovanissimo: fino a max 20 settimane di
età
Displasia lieve/moderata (Ortolani +, AR compreso
tra 15° e 35°, AS compreso tra 0° e 15°, Angolo
DAR tra 7° e 10°, Indice di Distrazione 0,4-0,7.).
Razze con masse muscolari degli arti pelvici poco
sviluppate (Pastore Tedesco, Labrador e Golden
Retriever).
Il successo di tale tecnica dipende
dalla capacità del medico
veterinario di selezionare i pazienti
displasici che potranno beneficiare
di tale procedura.
Necessaria attenta visita ortopedica
e buona diagnostica per immagini.
PROIEZIONE VENTRODORSALE CON DISTRATTORE
Per valutare LA LASSITA’ ARTICOLARE
(ID)
…Ma
Problematiche di natura etica…
Se faccio la sinfisiodesi a tutti i miei cuccioli…
essi riceveranno, alla lettura ufficiale, un
giudizio migliore….e nessuno se ne accorge!
anche se…
Grazie